The Intern At Work: Internal Medicine Silence of the Glands: An Approach to Male Hypogonadism
Dec 7, 2025
A tour through testosterone history and the HPG axis. Clear differences between primary and secondary hypogonadism are outlined. Practical testing tips on total versus free testosterone and optimal timing are covered. Clinical signs, red flags, and reversible causes to address before therapy are reviewed. Treatment options, monitoring, and recent cardiovascular trial findings are discussed.
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Historic Obsession With Testosterone
- Ancient cultures linked virility and strength to the testes and tried animal testicle remedies.
- Dr. Brown-Séquard injected himself with animal testicle extracts seeking youth, illustrating historical fascination with testosterone.
Physiology And Active Testosterone Fractions
- Testosterone regulates muscle, bone, libido, red blood cells, and fertility via the hypothalamic-pituitary-gonadal axis.
- Only free and albumin-bound testosterone are biologically active, so both total and free levels matter for diagnosis.
Targeted History And Physical Exam
- Take a focused history for sexual, systemic, psychiatric, reproductive, medication, and substance causes when suspecting hypogonadism.
- Examine for muscle loss, gynecomastia, decreased hair, testicular atrophy, and visual field defects to guide primary vs secondary evaluation.